Youth Suicide

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Aggression and Violent Behavior xxx (xxxx) xxx

Please cite this article as: Scott Poland, Sara Ferguson, Aggression and Violent Behavior, https://doi.org/10.1016/j.avb.2021.101579

Available online 15 February 2021 1359-1789/© 2021 Elsevier Ltd. All rights reserved.

Youth suicide in the school context

Scott Poland, Sara Ferguson *

Nova Southeastern University, 3301 College Ave, Fort Lauderdale, FL 33314, United States of America

A R T I C L E I N F O

Keywords: School mental health professionals Postvention Intervention School Prevention Youth suicide

A B S T R A C T

Across the domains of youth risk behavior, suicidality is a significant concern for parents and professionals alike, requiring ongoing efforts to better understand and prevent rising trends. Recent examinations of suicidal be- haviors in the United States over the last decade revealed an increase in emergency and inpatient hospital set- tings. Of importance, seasonal variations were demonstrated, finding the lowest frequency of suicidality encounters in summer months, and observed peaks in the fall and spring, during the school year. Given these findings and the fact that youth spend nearly half of their time at school, consideration of youth suicide in the school environment is critical. This paper will review the trends of youth suicide within the school context, exploring factors such as at-risk youth, bullying, relevant legal issues, and the current state of crisis response in school settings. Recommendations for prevention, intervention, and postvention will be provided. The authors propose that school professionals play a vital role in addressing youth suicide and will aim to provide guidance on effective crisis response within the school context.

1. Introduction

Suicide is a leading cause of death in the United States (CDC, 2018) and a prominent concern in the mental health and medical fields given the high rates of suicidal ideation and attempts. While death by suicide is an incredibly difficult and often unfathomable tragedy, its occurrence in the youth population can bring even more confusion and intense grief for loved ones. In 2016, suicide became the second leading cause of death for ages 10–34 (CDC, 2017b). Furthermore, a 2018 review of injury mortality among youth during 1999–2016 identified suicide as the second leading injury intent among 10–19 years (in which a 56% increase was observed between 2007 and 2016 [Curtin et al., 2016]).

The Youth Risk Behavior Surveillance Survey ([YRBSS], CDC, 2017a), the Centers for Disease Control and Prevention’s (CDC) biennial survey of adolescent health risk and health protective behaviors, revealed upward trends in their survey of suicidality and related be- haviors of high school students (see Fig. 1.1). Specifically, students re- ported an increase over the last decade in seriously considering attempting suicide and making a suicide plan. Of concern, among the few states that queried middle school students, trends were observed at an even higher rate.

Given the high rates of suicidal behavior among young people, ample research has been dedicated to this topic, resulting in pertinent knowl- edge necessary to better understand the matter. A variety of risk factors

have been consistently identified across the literature, many of which inform prevention and intervention practices for clinicians. There is, however, an area in which additional attention should be awarded: the school context.

Young people spend a significant portion of their time in school settings in which they are actively engaged with their peers and subject to the potential stressors of academic achievement and future success. In light of this, consideration of youth suicide in the school context is of utmost importance. Evidence reports that school influences the behavior and health of young people (Evans & Hurrell, 2016). This is additionally supported by recent research that has demonstrated significant seasonal variations in youth suicide patterns (Plemmons’ et al., 2018), suggesting that involvement in school should be further examined as a critical factor in youth suicidality.

This paper aims to contribute to this suggestion, in which we will review relevant literature related to youth suicide in the school context, including associated risk factors, existing prevention, intervention, and postvention programming, and related legal implications. Recommen- dations for best practices will be offered, specific to both school and mental health professionals. The authors propose that school pro- fessionals play an essential role in addressing youth suicide and will aim to offer guidance on effective crisis response within the school context.

* Corresponding author. E-mail addresses: [email protected] (S. Poland), [email protected] (S. Ferguson).

Contents lists available at ScienceDirect

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journal homepage: www.elsevier.com/locate/aggviobeh

https://doi.org/10.1016/j.avb.2021.101579 Received 1 December 2019; Received in revised form 19 July 2020; Accepted 5 February 2021

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2. Youth suicide & seasonal variations

As discussed, it has been well established that there are rising trends in youth suicidal behavior. Recent research in related domains supports these findings, such as observed increases in hospitalizations (Burstein et al., 2019), attempts by females (CDC, 2017b), use of suffocation as preferred method (Curtin et al., 2018), and serious considerations of suicide, along with the creation of a plan (CDC, 2017a). Plemmons’ et al. (2018) recent large-scale study examining youth suicidal encounters in pediatric emergency and inpatient hospital settings further supported the observed increases, demonstrating consistent upward trends of sui- cidal ideation and attempts across age groups and genders. Of interest, a pattern of seasonal variation was observed, in which a higher percentage of cases was found during the fall and spring and conversely, a lower number of cases during the summer months.

Such findings are of significance, as they shed light on a critical factor of youth suicide that has not been historically explored. Research related to this matter is limited and recent (see Hansen & Lang, 2011; Lueck et al., 2015), suggesting a gap in the conceptualization of youth suicide. Plemmons’ et al. (2018) findings of seasonal patterns lead one to consider the variables associated with the months in which increased and decreased rates were observed. Most glaringly, is the consideration of youth participation in school during the fall and winter months and the subsequent break during the summer months.

Lueck et al. (2015) set out to investigate this aspect of youth suicide, in which they analyzed the relationship between weeks in school vs. weeks out of school (i.e., vacation) with concern for danger to self or others. Of note, the researcher’s review of 3223 subjects (mean age, 13.8 years) who presented to a local pediatric emergency unit included youth with both suicidal and homicidal ideation, creating challenges in isolating the results solely to the examination of suicidal behavior. However, their findings of higher rates of such ideation during weeks in which the subjects were in school vs. the reduced rates observed during vacation weeks certainly contributes to the growing understanding that the school context has a significant impact on risk behaviors such as suicidality.

Similarly, Hansen and Lang (2011) hypothesized that youth in school served as a crucial factor in the seasonal patterns of youth suicide. Their

investigation established a distinct alignment of youth suicide with the school calendar, including a significant decrease during the summer breaks; one that commenced upon entering adulthood. Further, unlike many youth suicide studies, the researchers examined the data for each gender separately, finding that the suicide rate, on average, was 95% higher for boys in school months when compared to girls (33%). Addi- tionally, the authors proposed theories regarding school specific factors that likely influenced these trends, including negative peer interactions, along with academic stressors and the related mental health impact.

These findings create a scientific foundation for youth suicide in the school context that warrant a deeper investigation. Additionally, the authors would be remiss not to highlight the fact that youth spend nearly half of the total days of the year in school settings, thereby making it the most logical place to intervene. Access to the youth, along with potential resources within the school and community create an ideal environment for prevention and intervention. These factors create a cogent argument for continued exploration of youth suicide in the context of the school environment.

3. Risk factors in the school context

In light of the reviewed findings of seasonal patterns of youth suicide rates and their association to school participation, along with the sheer amount of time spent in the school setting, consideration of the school related factors that may contribute to youth suicidal behaviors is essential. Risk factors associated with youth suicide have been broadly identified, including specific individual and psychosocial variables. Such factors include youth that have little social supports, many of whom often present with pathologies such as mood and substance use disorders, bullies and victims, individuals who identify as LGBTQ, and youth exposed to adverse early childhood experiences such as trauma, family system disturbances, and most notably, suicide (Gould et al., 2003; Lieberman et al., 2008). Moreover, across the risk factors reviewed, of greatest significance is a prior suicide attempt. Research reveals that a prior attempt is the strongest predictor of a future death by suicide (Harris & Barraclough, 1997).

Fig. 1.1. YRBSS suicide related behavioral trends.

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3.1. Social connectedness

Specific to the context of school, a variety of risk factors are pertinent to review in detail. As mentioned, level of social support has been determined as a risk factor for youth suicide, in which a child or ado- lescent’s connectedness to his or her peers can play a significant role in his or her vulnerability to suicidal behavior (Lieberman et al., 2008). It is broadly accepted that the development of positive and close relation- ships with others can serve as a protective and preventive buffer against suicidal ideation and behaviors. Connectedness typically results in high rates of social contact and lower rates of feelings of loneliness and isolation (CDC, 2011).

While social connectedness has been established as a prominent factor in the conceptualization of suicidal behaviors (Joiner, 2005), it is important to consider this variable specifically in the context of youth suicide, given the easy access to potential social relationships (both negative and positive). Furthermore, it has been well documented that young people who are at higher risk for suicidal behaviors often face adversity such as familial disturbances and related neglect, homeless- ness, or involvement in social services (i.e., foster care), all of which negatively impact an individual’s level of connectedness. Lack of social connectedness in youth is a broad risk factor to consider and the related vulnerabilities that arise as a result are certainly contributing factors to suicidal behavior. Increased isolation, for example, can negatively impact self-esteem and potentially lead to depression, another identified risk factor of youth suicide (Lieberman et al., 2008).

The milieu of school provides an ideal setting to enhance social connectedness for children and adolescents. Moreover, it gives the op- portunity for school staff to act as warm and accepting social role models that can aid in providing a formal support system of connectedness. Recommendations for enhancing social support and connectedness as means to buffer suicide risk have been discussed across the literature, including the development of prevention programs that are founded upon this concept (e.g., Gatekeeping Training (Burnette et al., 2015; CDC, 2011)). While such programs (which will be reviewed in further detail) have been demonstrated as being an effective intervention for reducing suicide attempts in youth (see Aseltine et al., 2007; Aseltine & DeMartino, 2004), there are a variety of factors in school settings that not only create challenges in enhancing social connectedness across diverse student bodies, but also contribute to higher rates of suicidal behavior in young people.

3.2. Bullying

Relatedly, engagement in bullying (whether as the bully or the victim), has been identified as a risk factor for youth suicide (Holt et al., 2015; Lieberman et al., 2008). The Suicide Prevention Resource Center’s (SPRC) (2011) Issue Brief on Suicide and Bullying revealed a strong association between bullying and suicide, reporting that children who are bullied are at highest risk for suicide due to the commonality of risk factors. Dan Olweus, creator of the Olweus Bullying Prevention Program (1993), defines bullying as occurring “when a person is exposed repeatedly, and over time, to negative actions on the part of one or more persons, and he or she has difficulty defending himself or herself” (p. 9, Olweus, 1993). Lierberman and Cowan (2006) reported that interper- sonal problems are frequently cited by adolescents as the antecedent of suicidal behavior, in which loss of dignity and humanity is conceptu- alized as a triggering event. Moreover, Gould and Kramer (2001) pro- vided insight regarding bully behavior, suggesting that the more frequently an adolescent engages in bullying, the more likely that she or he is experiencing feelings of hopelessness and depression, has serious suicidal ideation, or has attempted suicide in the past.

The 2017 School Crime Supplement (National Center for Education Statistics and Bureau of Justice, 2018) found that in the United States, approximately 20% of students ages 12–18 experienced bullying. It is important to note that bullying can occur both in and out of the school

environment, especially given the rapidly evolving state of technology and social media. Cyberbullying is a growing concern (YBRSS data es- timates that 14.9% of high school students were electronically bullied in the 12 months prior to the survey [CDC, 2017a]). It is defined as any type of bullying (i.e., mean/hurtful comments, spreading rumors, physical threats, pretending to be someone else, and mean/hurtful pic- tures) through a cell phone text, e-mail, or any social media outlet or online source (Hinduja & Patchin, 2012).

Cyberbullying presents significant concerns related to its aspects of anonymity and ease of access. Moreover, it is pervasive and can occur in both the home and school setting, creating an environment of contin- uous bullying. The high frequency of cyberbullying is significant in the conceptualization of youth suicide in the school context, as students often have access to social media platforms where bullying frequently occurs during school hours. This likely contributes to the finding that reports of bullying continue to be highest within the school setting (U.S. Department of Health and Human Services, 2019). This is further sup- ported by the YRBSS data (CDC, 2017a), which revealed that nationally, 19% of students in grades 9–12 report being bullied on school property in the 12 months preceding the survey. While bullying has received increased public attention over time and actions have been taken to target the issue, it clearly persists in the school settings. More so, the findings certainly demonstrate the tragic and very permanent implica- tions that bullying can lead to in the context of youth suicide.

3.3. LGBTQ population

Given the significant findings related to bullying and suicidal behavior in children and adolescents, it is important to consider special populations that may be at higher risk of being bullied, as this may serve as an indirect route to suicidal behaviors. Children and adolescents who are questioning their sexual orientation or gender identity have been found to have high rates of negative outcomes in a number of areas including harassment, victimization, and bullying, along with violence, drug abuse, sexually transmitted diseases, and mental health problems, such as depression (Birkett et al., 2015; CDC, 2017a). Strikingly, this population has been found to be more likely to consider and attempt suicide (Almeida et al., 2009; Hatzenbuehler, 2011; Kosciw, Greytak, Bartkiewicz, Boesen, & Palmer, 2012; Lieberman et al., 2014). In fact, YRBSS (CDC, 2017a) data revealed significantly higher percentages of attempted suicides of lesbian, gay, or bisexual students (23.0%) and students not sure of their sexual identity (14.3%) when compared to their heterosexual students (5.4%).

Family acceptance appears to be a major factor in the experience of suicidal ideation, as those who experience a high level of acceptance are found to have lower rates (18.5%) when compared to those with low acceptance from their families (38.3% (Ryan, Russell, Huebner, Diaz, & Sanchez, 2010)). Furthermore, acceptance in other areas of a LGBTQ identifying youth’s life, such as the school and broader community, has been suggested as a significant protective factor to the many risks they face (Birkett et al., 2015), thereby promoting self-acceptance and resil- ience (Dahl & Galliher, 2012).

Consideration of the LGBTQ population in the school context is critical, as it can serve as an environment of safety, acceptance, and connectedness. There are a number of recommendations for school and mental health professionals to best support LGBTQ youth; however, despite the availability of specific recommendations (e.g., creation of safe-spaces and student-led advocacy groups), LGBTQ youth continue to widely report feeling unsafe at school (10%, CDC, 2017a), presenting serious ongoing concerns for this population. These findings, paired with the previously mentioned associated negative outcomes, including high rates of suicidal behavior, certainly justify the need for special attention and consideration in the school context.

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3.4. Ethnicity and culture

Consideration of high-risk populations must include the examination of suicide rates and related risk factors of young people across diverse ethnic and cultural backgrounds. While the prevalence rates of SI and SA vary among differing identifications of race and ethnicity, there are specific populations who have been identified as high risk for suicidal behavior (Lieberman et al., 2008). In 2017, The CDC (2017b) reported that the age-adjusted rate of suicide among American Indians/Alaska Natives was 22.15 per 100,000 and among non-Hispanic whites it was 17.83. In contrast, lower and more similar rates were found among Asian/Pacific Islanders (6.75%), Blacks (6.85%), and Hispanics (6.89%). YRBSS’ data reveals that Black or African American students reported the highest rate of suicide attempts (9.8%), followed by white students at 6.1% (CDC, 2017a). Of note, YRBSS did not include Amer- ican Indians/Alaska Natives as an option of ethnic identification; how- ever, the CDC (2017b) reported that suicide rates peak during adolescence and young adulthood among this population and then decline. This pattern greatly differs from the general United States population, where rates of suicide peak in mid-life.

The disproportionate level of risk for suicide in youth who identify as American Indian and Alaska Native has been well researched, in which a variety of contributing factors have been identified, e.g., high rates of substance use, exposure to adverse early childhood experiences, limited access to resources due to rural settings, and increased potential for contagion effects of suicide (Leavitt et al., 2018). In light of these complex vulnerabilities, researchers often recommend school involve- ment in prevention and intervention to target the varied risk factors present, especially as they relate to suicidal behavior. School program- ming can typically reach larger populations, a dire need in rural areas in which many of these young people reside (Leavitt et al., 2018; Lieber- man et al., 2008). Specific recommendations within the school context are offered across the relevant literature, which will be integrated into clinical recommendations in later reading.

4. Legal implications of suicide in the school context

Suicide in the school context is a complex issue that can create sig- nificant legal implications regarding the liability of the school district and staff, especially administrators, support staff, and school psycholo- gists. In the United States, there have been numerous legal battles in which schools are sued in the aftermath of a death by suicide of a young person. While this presents major concerns for school personnel, very rarely do the parents of suicidal students succeed in court proceedings. With the exception of the school’s failure to notify parents when there is reason to suspect a student’s risk for suicide, courts have been reluctant to find schools culpable (Stone, 2017).

Friedlander (2013) reported that parents as the plaintiffs face slim chances when they file a lawsuit against the school or its officials after the suicide of their child. Many factors contribute to this, including the lack of resources, i.e., financial means, the lengthy trial periods, and limited evidentiary documentation. Cases that cite bullying as a critical factor in the youth’s suicide, for example, often lack the necessary documentation of the parents’ concerns that are often reportedly shared with school officials prior to their child’s death by suicide.

Moreover, Poland (Erbacher, Singer, & Poland, in press) reported that only a small number of these cases make it to a jury trial. More often, the school districts’ insurance companies decide to settle the cases outside of court, as it can be a less costly and public matter, when compared to the potential of a lengthy defense of the district in litiga- tion. Moreover, public legal battles can generate a negative stigma around the school and its district. However, MacIver (2011) suggested that the number of court cases against schools may continue to rise in the future, as courts are becoming more receptive to finding the defendants liable for causing another person’s suicide. Further, suicide experts are reported as having increased success in either proving or disproving a

specific cause of suicide. In review of cases that have gone to trial, rulings are varied,

muddying the legal guidelines for school suicide prevention and related liability. Dr. Scott Poland, one of the present authors and a leading expert in youth suicide, discussed the complexity of these cases in his chapter on Legal Issues for Schools (Erbacher et al., in press). In sum, courts must primarily consider whether a student’s death by suicide was a direct result of an inadequate response from the school personnel; however, given the varied psychosocial risk factors associated with youth suicide (e.g., mental health, and adverse childhood experiences), it is highly difficult to prove that a school’s breach of duty is the sole causal factor of the suicide, thereby making the personnel liable.

4.1. School liability: relevant legal cases

What then is the school’s liability in cases of student suicides? His- torically, courts ruled that schools did not have a legal obligation to prevent suicide (Stone & Zirkel, 2012). A 1991 appellate case, Eisel v. Board of Education of Montgomery County, set new precedent on this matter. The father of 13-year-old Nicole Eisel sued the school district and two of its school counselors after they failed to report their learning of an apparent murder-suicide pact with another peer. The father argued that the special relationship the personnel maintained with his daughter placed a duty upon them to share her reported suicidal ideation with her parents. The Maryland Supreme Court held that the state’s Suicide Prevention School Programs Act, the school’s own suicide prevention policy, and the relationship between school, counselor, and youth gave rise to a duty on the counselors’ part to use “reasonable means to attempt to prevent a suicide when they are on notice of a child or adolescent student’s suicidal intent” (Eisel v. Board of Education of Montgomery County, 1991), including, at a minimum, a report to the student’s parents. The Court listed “foreseeability of harm,” i.e., a reasonable person would have been able to recognize that a student was in an acute emotional state of distress and in danger of suicide, as the prominent factor in determining whether school employees had a duty to warn student’s parents (Eisel v. Board of Education of Montgomery County, 1991; Friedlander, 2013).

While this was significant regarding the role of school professionals, it did not create an absolute precedent of liability for schools. In fact, the very same school district cited in the 1991 case was sued just a few years later after another student’s suicide in Scott v. Montgomery County Board of Education (1997), in which the court did not adhere to the precedent of liability for school mental health professionals (SMHPs). A federal appellate court upheld the dismissal of the lawsuit initiated by the mother of a middle school student who had hanged himself. The school psychologist met with the student approximately two months prior to the student’s suicide and did not assess him as posing an im- mediate danger of self-harm; furthermore, did not report the informa- tion to the student’s parents. The court dismissed the mother’s claims of negligence as educational malpractice, concluding that the alleged causal linkage to the school psychologist was not sufficient (Scott vs. Montgomery County Board of Education, 1997; Stone & Zirkel, 2012).

Court cases post Eisel (1991) in many states have continued to consider school districts or personnel liability for student suicides. Friedlander (2013) relayed that among these cases, claims of negligence that are grounded in “statutory, regulatory, or district policy for suicidal threats and suicide prevention” (Friedlander, 2013) are most promising to plaintiffs. Negligence is a breach of duty owed to an individual involving injury or damage (suicide) that finds a causal connection be- tween a lack of or absence of duty to care for the student and his/her subsequent suicide (Stone, 2017).

In Wyke v. Polk County School Board (1997), for example, the Eleventh Circuit Court of Appeals concluded that the school board was liable for the death of 13-year-old Shawn Wyke. Wyke hanged himself at his home two days after two failed attempts were completed at school. His mother, Carol Wyke utilized the “failure to train theory” arguing that

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the lack of suicide prevention/intervention training for the school personnel demonstrated a direct indifference to their duty to care and protect (Erbacher et al., in press). While the school board argued that suicide is an intervening force, the jury found that the school was “somewhat aware” of the attempts on campus and made no efforts to intervene, i.e., hold the child in protective custody, recommend, pro- vide, or obtain protective counseling for the student, or report the in- cidents to his parents. Further, the Court concluded that given the known attempts, the school personnel had strong reason to anticipate the suicide which was thus, foreseeable (Erbacher et al., in press; Friedlander, 2013; Wyke v. Polk County School Board, 1997).

Negligence and foreseeability are not the only factors that have been identified in determining school liability in student suicides. Sovereign immunity, for example, has been used in school related suicide cases. Government entities are granted immunity if their conduct does not clearly violate constitutional rights of which a reasonable person would have known. There is a constitutional right of a duty to protect students and state laws require compulsory attendance for students; however, legal cases have failed to find that a child’s required attendance at school creates a relationship that would mandate a school’s duty to protect students. Immunity is based on state law; if the state deems schools an arm of the state government, then schools within that state are granted sovereign immunity (Erbacher et al., in press).

Additionally, a school can be found in violation of legal re- sponsibility based on the constitutional rights of the victims, i.e., state created danger. The school may be liable if it does not enact or follow through with specific policies and procedures, thereby causing danger to the student who died by suicide (Erbacher et al., in press; Sanford v. Stiles, 2006). Lastly, many school attorneys use the “intervening force” argument to defend the school and its personnel, stating that suicide is a superseding and intervening force that breaks the direct connection between the defendants’ actions, i.e., failure to notify parents, and the suicide. In sum, the intervening force is the real reason for the suicide that resulted and the longer the timeframe between the possible negli- gence of the school and the suicide of a student, the more logical the intervening force argument (Erbacher et al., in press).

4.2. Legislation

The major legal implications of youth suicide in the school context certainly justify the need for state laws and mandates targeted at suicide prevention and intervention in the school setting. In the past, district- wide suicide prevention efforts oftentimes only occurred after the occurrence of a tragic student death. Currently, a majority of states require some type of suicide prevention training for their school personnel. However, the programming, efforts, and quality vary state by state (Kreuze et al., 2017; Singer et al., 2018).

The American Foundation of Prevention for Suicide (AFPS, 2019) reviewed current state laws in the United States, finding varied policies and procedures related to prevention programming. To date, 11 states require mandated annual training; moreover, 20 states (40%) also require mandated training, but without the yearly contingency. Many states without mandated training are making efforts to encourage training throughout school districts; further, many require the provision of suicide prevention and intervention policies and procedures (AFPS, 2019).

The Garrett Lee Smith Memorial Act (2004) was the first bill signed into law pertaining to suicide prevention among young people in the United States. It affirmed suicide as national public health problem and intended to provide funding to states, tribes, campuses, and behavioral mental health services for grants that support prevention and inter- vention efforts. In 2007, a hallmark piece of legislation, the Jason Flatt Act, was passed in the state of Tennessee, requiring all educators in the state to complete 2 h of youth suicide awareness and prevention training each year in order to be able to be licensed to teach. The Tennessee legislation now serves as the model to introduce the Jason Flatt Act

(2007) in other states. It’s founders, Jason Foundation Inc. (a non-profit agency dedicated to bringing suicide prevention awareness and educa- tion to schools), report that to date, 20 states have adopted the act (although each state’s requirements vary [AFPS, 2019]) and have been supported by the state’s Department of Education and the state’s Teacher’s Association, highlighting the value observed in such preven- tative training (Erbacher et al., in press; JasonFoundation, 2019).

AFPS (2019) is dedicating major advocacy efforts toward the adop- tion of the Jason Flatt Act (2007) in states that are still lacking in legal mandates for suicide prevention. For these states, AFPS has created a model legislation that can be used as a guide for individuals who would like to lobby for the passage of this type of training. Lobbyists and ad- vocates report frustrations in their continued efforts, particularly regarding the language used in the adoption of policies and procedures. One critique, for example, is the state’s use of the word “recommended” instead of “required” in suicide training for schools (Lieberman & Poland, 2017). Nevertheless, ongoing pursuits for mandated prevention programming and training for school personnel are imperative, as they have been demonstrated as significant lifesaving and life changing legislation.

5. Addressing youth suicide in the school context

The content reviewed thus far has set forth a solid foundation for the argument that increased attention must be dedicated to youth suicide in the school context. Comprehensive research on broad suicidality has acted as a crucial guide to informing professionals and the general public, creating more awareness and understanding surrounding the topic. It has generated helpful statistics that shed light upon specific factors that are associated with suicidal behaviors in children and ado- lescents. The identified risk factors discussed are key findings that inform suicide response practices in the school setting; best practices to target youth suicide include health promotion, prevention, intervention, and postvention (Gould et al., 2003; Katz et al., 2013).

5.1. Prevention

The World Health Organization (WHO, 2019) emphasizes the fact that while suicide is a significant public health concern, it is one that is preventable, with timely, evidence-based and at times, affordable in- terventions. The conceptualization of youth suicide as a public health problem prompted the United State to adopt a public health model of its prevention. “The public-health approach focuses on identifying patterns of suicide and suicidal behaviors in a group or population. It aims at changing the environment to protect people against diseases and changing the behaviors that put people at risk of getting them” (p. 118, Yip, 2011). While suicide is not considered a “disease” in the traditional sense, it is a significant public health concern. Moreover, given the legal implications discussed and the very real preventability of such tragic deaths, school personnel, specifically SMHPs, must understand the importance implementing suicide prevention programs via the lens of public health in order to reduce suicide risk and suicide rates among the adolescent population (Lieberman et al., 2014).

Prevention strategies for this population are traditionally completed in three domains, including community, healthcare systems, and school. The primary goal of prevention programs is to reduce the prevalence of suicidal behavior in the youth population (Katz et al., 2013). Ancillary goals include identification of at-risk individuals and the completion of appropriate referrals and treatment targeting risk factor reductions (Gould & Kramer, 2001; Gould et al., 2003). Given the sheer amount of time that youth spend in the school setting, school-based programs have been suggested as being perhaps the most effective way to reach this population (Calear et al., 2016; Miller et al., 2009).

5.1.1. School suicide prevention programs A variety of school-based suicide prevention programs exist;

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however, systematic reviews reveal that the field has yet to find a definitive, evidence-based, best practice guideline (Calear et al., 2016; Gould et al., 2003; Katz et al., 2013). While prevention programming varies across design, methods, and implementation, common recom- mendations are observed across the literature. AFPS (2019) has devel- oped four evidence-based frameworks for youth in the U.S. for ensuring success of suicide prevention strategies, including gatekeeping (i.e., training those considered to be natural helpers to recognize signs and symptoms of suicide [Katz et al., 2013]), psychoeducation, restriction to access of lethal means, and provision of mental health treatment to students with depression and/or anxiety disorders, or those at risk for such disorders (Lieberman et al., 2014). Additionally, the U.S. Depart- ment of Health and Human Services Substance Abuse and Mental Health Services Administration (SAMHSA, 2012), has developed “Preventing Suicide: A Toolkit for High Schools” that outlines a plan on how to educate school personnel, students, and parents on youth suicide and related behaviors. Lieberman et al. (2014) relayed that SAMHSA’s guidelines are highly regarded methods that target the identification of at-risk youth and the use of appropriate protocols for these students. Additionally, the toolkit offers suggestions for evidence-based suicide prevention programs that are well matched for the school setting (SAMHSA, 2012).

Katz et al. (2013) comprehensive systematic literature review examined a number of school-based suicide prevention programs, including, but not limited to suicide awareness curricula, general skills training, and peer leadership. Ultimately, the investigators concluded that while there are numerous available programs, few are evidence based; importantly, the research lacks randomized controlled trial (RCT) studies that evaluate their effectiveness on the outcome of suicide. Suggestions for best practices include the combined use of multiple programs in order to address the varied and complex needs of youth suicide in the school context.

Cooper et al. (2011) drew similar conclusions in their systematic review of high school-based suicide prevention programs in the United States, in which they recommended a hybrid approach that includes elements from the various programs reviewed. Of note, the authors re- ported that across the most commonly used programs, four types were isolated, including enhancement of protective factors, screening tools, gatekeeper trainings, and curriculum based. Programs that enhance protective factors were described as those that aim to identify problem solving skills, means to adaptively cope, and the promotion of devel- opmentally appropriate mental health. As mentioned previously, gate- keeping utilizes a training approach in which school personnel and sometimes peers work to increase their skills related to the identification of and response to suicidal behavior in the school environment. Addi- tionally, screening methods, such as depression screening tools, are used to gain objective measures of student self-report of suicidality and related risk factors. Lastly, curriculum-based programs emphasize the importance of addressing mental health factors, including the use of training materials that educate school personnel on suicidality and at risk-youth (Condron et al., 2015; Cooper et al., 2011). Kalafat (2006) highlighted that while aspects of these programs are critical components of effective suicide prevention planning, there is little evidence to prove they are effective as stand-alone programs; however, these four cate- gories warrant deeper review, including a brief discussion of existing programs that fall within respective types of prevention programming.

5.1.2. Enhancement of protective factors Common protective factors for at risk youth have been identified,

including family cohesion and stability, strong coping and problem- solving skills, positive self-worth, connections to school and extracur- ricular participation, academic success, and enhanced impulse control (WHO, 2014). Self-esteem and social support are two critical protective factors that buffer the risk of suicide. When the availability of peer and family support is present, suicide risk decreases, as self-esteem increases (Eisenberg & Resnick, 2006; Kleiman & Riskind, 2013; Sharaf et al.,

2009). Further, stronger levels of resiliency have been found in in- dividuals with higher self-esteem (Sharaf et al., 2009). These factors are significant in the conceptualization of youth suicide prevention plan- ning and can be enhanced in programs that emphasize protective fac- tors. Kalafat (2006) reported that research findings (Jessor et al., 1995) have demonstrated that prevention strategies targeting the enhance- ment of protective factors may be more effective than those that address risk factors. Despite this, such programs are not recommended as lone practices, as they do not fully account for the complex needs present in youth suicidality.

Promoting CARE, for example, is a school and home-based program that primarily targets the enhancement of protective factors (i.e., per- sonal and social resources) in suicide-vulnerable high school youth. It incorporates principles of behavior change maintenance as means to increase skills acquisition, motivation, social support, and self-efficacy. The program implements strategies aimed to decrease negative behav- iors via the improvement of emotional management, interconnected- ness, and coping skills. Its design is based on the empirical findings that have demonstrated that interventions that emphasize motivation to change, social support access, and self-efficacy (i.e., the confidence that an individual is equipped with the ability to face life challenge and ac- cess learned skills), increase the likelihood of skill acquisition, behav- ioral change, and continued maintenance of change (Cooper et al., 2011; Hooven et al., 2010; Hooven et al., 2012).

Hooven et al. (2010) analyzed the longitudinal data of the long-term maintenance of achieved short-term changes of 615 high school youth and their parents, all of whom had participated in the Promoting CARE program in the United States. A review of the identified at-risk adoles- cents in the short-term and up to eight years post engagement in the program revealed a decrease in key risk factors, including suicidal be- haviors, depression, and hopelessness, along with an increase in pro- tective factors such as family connectedness, self-efficacy, and coping skills. The most effective components of the program were found to be two, two-hour home visits with parents paired with two expert-led meetings with students that were held two and half months apart. Parent meetings were psychoeducational in nature, along with the development of specific strategies to utilize with their adolescent. The student meetings included assessment and counseling, with an emphasis on family connectedness and adequate preparation for school personnel. Given these findings, Hooven and colleagues urged the field the broaden their scope of research to further strengthen the evidence behind this and other kinds of suicide prevention plans that enhance protective factors. Moreover, these findings align with the ongoing mission of schools to implement programs that focus on protective factors (Kalafat, 2006), albeit they present difficulties in implementation, i.e., consistent involvement of outside parties (parents).

5.1.3. Screening tools Among the prevention strategies reviewed, case-finding via direct

screening of youth, i.e., self-report screening tools, has received increased attention (Gould et al., 2003; Singer et al., 2018). Self-report and individual interviews have been demonstrated as being helpful aids in the identification of youth who are at risk for suicide (Gould et al., 2003; Reynolds, 1991; Shaffer & Craft, 1999; Singer et al., 2018; Thompson & Eggert, 1999) and target the fluid nature of suicidality (Pisani et al., 2016). Further, while it is commonly thought that suicide is an impulsive action, research contradicts this, revealing that in- dividuals considering suicide spend a range of time contemplating and planning (Millner et al., 2017).

Screening is a method that involves screening either at-risk students specifically, or all students at a school, in which those who are found to be at increased risk are referred to treatment. Screening tools typically examine specific risk factors such as substance use, depression, and past suicidal behaviors. One of the most critical components of the screening programs is the availability of adequate referral sources prior to the screening taking place (Katz et al., 2013). This can present challenges in

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follow through. As discussed previously, there are often limited re- sources available (particularly in rural areas), especially providers who are competent to provide youth suicide intervention.

Additional limitations of screening programs include the fluctuating nature of mental illness. A student who is screened in September, for example, may report an entirely different experience of symptoms later in the school year. Without multiple screenings, it is difficult to assess risk factors that vary with time (Ciffone, 2007). Furthermore, critics report concerns over the potential for generating both false positives and negatives (Ciffone, 2007; Gould et al., 2005). However, Gould et al. (2005) found that suicidal youth who were not asked about suicide were more distressed than those who were asked about it via the screening tools used, ultimately concluding that screening programs are a safe method of suicide prevention in schools. These programs are further supported in the literature (Lieberman et al., 2014; Scott et al., 2009). For example, Peñta & Caine’s, 2006 systematic review of 17 screening tools used to detect adolescents who were at-risk for suicidal behaviors demonstrated improved identification; however, the positive predictive value of any related suicidal behavior in school settings was low across the reports (range 6–33% [Peñta & Caine, 2006; Zalsman et al., 2016]).

A variety of screening methods are available; however, consistent with other prevention programming, there is not a clear consensus on which tool should be primarily used. Cooper et al. (2011) cited three well known screening tools that are most often used in school prevention programs, including the Suicide Risk Screen (SRS), the Suicidal Ideation Questionnaire (SIQ), and the Columbia Suicide Screen (CSS). Leading experts in youth suicide, Lieberman et al. (2014) provided specific recommendations for SMHPs that would enhance their ability to not only identify potential suicidality in students, but also important risk factors that may lead to a trajectory of suicidal behaviors. As such, while several of the suggested screening tools target suicidal behavior directly (e.g., The Columbia Suicide Severity Rating Scale [Posner et al., 2011], MAPS: Measure for Adolescent Potential for Suicide [Eggert et al., 1994], Brief Suicide Risk Assessment Questionnaire [Miller & McCo- naughy, 2005]), the authors also include screeners that examine other relevant factors, such as depression (e.g., Reynolds Adolescent Depres- sion Scale-Second Edition (Osman et al., 2010)), and The Hopelessness Scale for Children (Kazdin et al., 1986). Despite the multitude of rec- ommendations, it is important comment on the fact that, consistent with previous recommendations, screening tools should not be used as pre- ventive methods alone; rather, in conjunction with other successful programming.

5.1.4. Gatekeeper trainings Gatekeeper training has become a broadly adapted model of suicide

prevention that has been integrated into other models, e.g., curriculum- based programs. As mentioned earlier, gatekeepers are identified help- ing adults, i.e., teachers, school counselors, coaches, clergy, etc., who are in a position to both observe and intervene with at-risk adolescents. The training emphasizes increased identification and response skills of these adults (Stein et al., 2010). Within the school context, the use of gatekeeper training is grounded in the concept that young people who are at-risk for suicide are under identified and that by providing adults with psychoeducation regarding suicide, identification can increase. This training can enable school professionals to gain knowledge, atti- tudes, and skills that aid in their identification of students who are at risk, determine their levels of risk, and make appropriate referrals for treatment as needed (Garland & Zigler, 1993; Gould et al., 2003; Kalafat & Elias, 1995). Critics have discussed a few limitations to gatekeeping in the school context, namely related to the availability of necessary adults and the level of connectedness students who are at-risk may have, thereby limiting the likelihood that they would share their SI with friends (Kalafat, 2006).

As with the other domains of prevention, extensive empirical research, including the necessary RTC studies, of Gatekeeper Trainings are limited. However, some findings, inclusive of the above mentioned,

have suggested that it is an effective program to improve knowledge, attitude, intervention skills, preparation for coping with a crisis, and referral practices; moreover, reports indicate a general satisfaction with the training (Gould et al., 2003; Katz et al., 2013). These factors are thought to contribute to increased identification and adequate crisis response to suicidal students on behalf of school personnel. Further, it has been reported as a more widely accepted training by administrators when compared to school-wide screening programs (Katz, 2013).

Among the commonly used gatekeeper training programs (e.g., LivingWorks, Yellow Ribbon International for Suicide Prevention, and Suicide Options and Relief), Question Persuade Refer (QPR; Quinnet, 1995) has been repeatedly recommended in the literature (Burnette et al., 2015; Gould et al., 2003; Kalafat, 2006; Tompkins et al., 2009). It is a program that provides one to two-hour training sessions to in- dividuals wherein they achieve the following objectives: (1) learning to recognize warning signs, (2) question suicidal intent, (3) listen to problems, and (4) refer for help (Tompkins et al., 2009). Tompkins et al. (2009) empirical review of QPR resulted in a positive evaluation in which significant gains in knowledge and attitudes related to suicide were observed from pre- to post-test, providing support for the continued use of QPR as a school-based prevention program.

5.1.5. Curriculum based programs Curriculum-based programs have greatly evolved over the course of

the last two decades and are another popular method of suicide pre- vention programming. Such programs aim to provide psychoeducation and increased awareness regarding suicide via school curriculum. Thus far, the curriculum is largely geared for the middle and high school populations (Cooper et al., 2011). Currently, the majority of these pro- grams are part of the comprehensive universal school-based prevention programs (i.e., those that target an entire population vs. selected in- dividuals/populations [Kalafat, 2006; Singer et al., 2018]).They are designed to reflect a hybrid model (in line with previously discussed recommendations), in which screening and gatekeeping aspects are included, thereby increasing the likelihood of identifying at-risk stu- dents (Katz et al., 2013). Kalafat (2006) cites the empirical base for these programs as that there is a higher likelihood that at-risk youth will tell a peer about their thoughts or plans and that most of these peer confidants do not relay this information to an adult. Moreover, school-based adults have been cited as the last choice for youth to turn to for their diffi- culties. As such, these programs are developed to increase the likelihood that gatekeepers and peers are more readily able to identify at-risk students and can subsequently provide appropriate interventions and referrals (Kalafat, 2006).

Ciffone (2007) provided a thorough review of curriculum based programs and recommended the use of two tier program model, in which the primary strategy includes an “authoritative delivery of a well- designed curriculum-based prevention message” (p.42, Ciffone, 2007) followed by the secondary strategy of screening that will aid the school personnel in identifying students who are at-risk for suicidal behaviors. Curriculum-based programs have been cited as being beneficial in improving suicide and mental health related knowledge and attitudes (Guo & Harstall, 2002; York et al., 2012); however, there is limited evidence for the prevention of suicidal behavior (Mann et al., 2005). Critics shed light on the fact that changes in knowledge and attitude are not necessarily correlated with changes in behavior. (Katz et al., 2013). Despite this, curriculum-based programs in the school context are a promising direction for prevention and, unlike most of the other models, have some empirical evidence behind specific program models.

Signs of Suicide (SOS; Mindwise Interventions, 2019) is a long- standing, school-based suicide prevention program that includes both curriculum and screening (Singer et al., 2018). A variety of national organizations that specialize in youth mental health and suicide pre- vention have served as sponsors of the SOS program, ranging from the National Association of School Psychologists (NASP), to the National Association of Secondary School Principals. This prevention plan

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integrates two frameworks: (1) heightened awareness via psycho- education for students and school staff about recognition of warning signs of depression and suicide, along with avenues for intervention, and (2) a self-report measure that screens for the presence of depression and suicide risk (Lieberman et al., 2014). A key factor to implementation includes the training of students to be gatekeepers, in which they are taught that suicidal behaviors are not a normal response to life stressors (as historically conceptualized), rather, an emergency that should be shared with a responsible adult (Cooper et al., 2011). Additionally, SOS includes a kit of materials per grade groups, beginning with eighth grade. The kit includes teaching materials (a video and discussion guide), along with the Brief Screen for Adolescent Depression (Lieber- man et al., 2014; Mindwise Interventions, 2019).

SOS has been proven as an effective method of prevention in the school context. Drs. Aseltine and Demartino (2004) completed a large- scale RCT examining the effectiveness of SOS in reducing suicidal be- haviors. The subsequent study (Aseltine et al., 2007) expanded upon this analysis, including a second year of data and an additional examination of efficacy variation among different types of students. Both studies found that students involved in SOS demonstrated significantly decreased rates of SAs, along with increased knowledge and a more adaptive attitude regarding depression and suicide. Further, specific factors such as race/ethnicity, grade, and gender did not impact the intervention outcomes evaluated (Aseltine et al., 2007; Aseltine & DeMartino, 2004). While this curriculum prevention program has been proven effective, researchers acknowledge their lack of knowledge regarding the long-term effectiveness of models like SOS (Aseltine et al., 2007). Regardless, it is still a prominent recommendation among experts (Aseltine et al., 2007; Aseltine & DeMartino, 2004; Gould et al., 2005; Lieberman et al., 2014) and incorporates a variety of the recommended program components (e.g., screening, gatekeeping, psychoeducation) into one comprehensive school suicide prevention program.

5.1.6. Peer leadership While not included in the above domains, it is important to highlight

another area of school-based suicide prevention that is gaining more attention in the recent years. Peer leadership programs are founded upon the associations between suicidal behavior and adolescents’ social ties and norms. Suicidal adolescents are found to have increased con- nections to other suicidal youths; moreover, adolescents who have a friend who attempts suicide are 2 to 3 times more likely to make an attempt themselves (Bearman & Moody, 2004; May et al., 2012). Exposure to peer suicidal behavior may result in the promotion of a perceived norm that a common response to distress is suicidal behavior, thereby increasing a student’s susceptibility to suicide imitation. Acceptance of suicide has been associated with increased suicidal be- haviors and planning (Wyman et al., 2010).

Peer leadership programs enact changes from within the student population, in which socioecological protective influences are learned and translated across the student body. Given the fact that students are more likely to discuss their suicidal thoughts with peers rather than adults (Katz et al., 2013), placing preventing in the hands of students is a logical route. These programs often aim to revise the norms that are perpetuated among peer groups in order to alter perceptions of what is typical behavior and of the consequences for positive coping behaviors (Wyman et al., 2010). The framework is centered on the training of diverse student representation, in which students are taught how to respond appropriately to a friend’s report of suicidal thoughts, including when to seek a trusted adult. Additionally, a key goal is to aid in implementing positive coping norms within the school setting and a culture of prosocial and help seeking behaviors.

HOPE Squad (2018), is a “peer to peer” based program that partners with local community and mental health agencies to train students to be empowered to take action to prevent suicide. Students are nominated by their classmates as trustworthy peers and are then trained to recognize the signs of suicide, be active listeners, provide friendships, and seek

assistance from a trusted adult when necessary. The goals of HOPE Squad are to prevent suicide and reduce behaviors by creating an environment that promotes positive relationships among students and culture of openness to talk about suicide and acceptance to seek help across schools and communities. The HOPE Squad Program originated in the state of Utah, the nation’s 5th leading state for youth suicide and has been successfully implemented in three different school districts. Moreover, it has been determined by the Utah Evidence-Based Work group to be a Level 3, Supported Program and Practices. HOPE Squads are on the Utah State Office of Education approved suicide prevention programs list and have support from the Utah legislature (Hope Squad, 2018).

Sources of Strength is another peer-based suicide prevention pro- gram that has garnered increased attention and research in the last several years (Singer et al., 2018). The program attempts to generate a diverse group of peer leaders who can positively affect a broad range of cliques within a school or community. Student leaders are recruited through teacher, staff, and peer nominations and are trained to model and encourage other peers to “(1) name and engage ‘trusted adults’ to increase youth–adult communication ties; (2) reinforce and create an expectancy that friends ask adults for help for suicidal friends, thereby reducing implicit suicide acceptability; and (3) identify and use inter- personal and formal coping resources” (Sources of Strength, n.d.; Wyman et al., 2010). Wyman et al. (2010) completed one of the nation’s largest studies on peer leaders and their impact on suicide prevention, focusing on the implementation of Sources of Strength. The results were in favor of the program, demonstrating an increase in both peer leaders’ connectedness to adults and in school engagement, along with an in- crease in positive perceptions of adult support for suicidal youth and the acceptability of seeking help. Further, peer leaders in larger schools were found to be four times more likely to refer a suicidal friend to an adult, fulfilling the primary goal of prevention in the context of youth suicide.

5.2. Intervention

The majority of research regarding suicide in the school context primarily focuses on prevention as the means for intervention, especially given the reported preventability of these tragic deaths. Experts emphasize the importance of early identification and intervention. However, the literature has demonstrated that despite the broad avail- ability of school-based suicide prevention programs, few are evidenced based and there has yet to be a national consensus of specific pro- gramming to use. Moreover, given the trends reviewed earlier, youth suicide during school months continues to be a major public health concern that school personnel may have to address at some point in their careers.

Comprehensive intervention policies and procedures ensure that school personnel have specific guidance around and are supported in intervening with students experiencing SI or who have engaged in a SA. AFPS (2019) reports that such policies will enhance clarity regarding educators’ roles and empower them to effectively intervene in the face of student suicidal behavior. The SAMHSA (2012) toolkit strongly rec- ommends for the placement of protocols in every school in order to specify which individual(s) will handle each of the tasks in the event of a suicide risk, suicide attempt, or completed suicide. Two key components that must be in place even if the school does not provide further suicide prevention strategies include, “protocols for helping students at possible risk of suicide” and “protocols for responding to a suicide death (and thus preventing additional suicides)” (p. 17, U.S. Department of Health and Human Services Substance Abuse and Mental Health Services Administration, 2012).

Collaborative efforts of the American Foundation for Suicide Pre- vention, the American School Counselor Association, the National As- sociation of School Psychologists, and The Trevor Project resulted in the development of the “Model School District Policy on Suicide Prevention”

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(AFPS et al., 2019). The model is not a specific program, rather a guide for the development and implementation of comprehensive school dis- trict policies on suicide prevention. It offers recommended language for school district policies that target suicide risk, prevention, intervention, and response in young people. Further, it includes suggestions for best practices, commentary, and resources pertaining to youth suicide pre- vention. Leading experts in the field, such as Drs. Lieberman et al. (2014) and the National Association for School Psychologists (2015) have provided recommendations for best practices in suicide prevention and intervention, much of which aligned with those offered in the Model Policy (AFPS et al., 2019). Key factors are consistently identified across the literature, including (1) prevention via early identification, (2) proper risk assessment, (3) appropriate referrals (e.g., notification of parents and SMHPs, treatment resources), and (4) re-entry procedures.

5.2.1. Identification of at-risk youth It has been well established that the school and its personnel play a

critical role in suicide prevention for students. AFPS et al. (2019) rec- ommends that school districts assign a suicide prevention coordinator that provides assistance in planning and implementing prevention pol- icies at the district and school levels. Given the limited availability of staffing and resources in many districts, alternative recommendations include the incorporation of SMHPs (e.g., school counselors, social workers, or preferably school psychologists—as they are trained in psychological assessment) or other school personnel that can be prop- erly trained (Lieberman et al., 2014). These individuals should serve as the point of contact when there is concern regarding an at-risk student (AFPS et al., 2019).

Of utmost importance, is the training of these individuals and the broader school personnel in early identification of common warning signs (Singer et al., 2018). While many youths who are at-risk for sui- cidal behavior go unnoticed, the majority of them demonstrate clues to their distress in some form. These warning signs are the foundational concept to the need for gatekeepers and it is recommended that these individuals are trained to identify and respond appropriately to them (Lieberman et al., 2014). There are various warning signs of youth sui- cide (Poland & Lieberman, 2002; U.S. Department of Health and Human Services SAMHSA, 2012) including (1) threats that can be passive (e.g., what’s the use?) or direct (e.g., “I want to die”) in nature, (2) plan/ method/access—the presence of a plan, availability of a method, and access to means increases the risk of suicidal behavior, (3) making final arrangements (e.g., giving away possessions, writing goodbye notes, reporting sense of purposelessness) and (4) observed sudden changes (e. g., in behavior—social withdrawal, mood, personality, friends). Any recognition of such clues for potential at-risk behavior should never go unaddressed as they are strong predictors for suicide.

5.2.2. Risk assessment Identification of at-risk youth is of utmost important in the preven-

tion of youth suicide. Suicide screeners are often used as means to identify students who are in need of more in depth risk assessment. Erbacher, Singer, and Poland (2015) developed a formatted suicide screener, Suicide Risk Screening Form, that included five direct questions for a student in which suicidality is suspected: 1) Have you wished you were dead?, 2) Have you felt that you, your friends, or your family would be better off if you were dead?, 3) Have you had thoughts about killing yourself?, 4) Do you intent to kill yourself?, 5) Have you tried to kill yourself? (p. 95).

Upon identifying at-risk youth, a thorough risk assessment must be completed. There should be at least one professional in the school setting that is trained to complete a thorough risk assessment. AFPS et al. (2019) describes risk assessment as an evaluation aimed to elicit specific in- formation related to a student’s intent to die by suicide—inclusive of a plan and level of lethality and availability, along with his/her previous history of SI, mental status, presence of support systems and other risk factors, and levels of helplessness. Kennebeck and Bonin (2019)

expanded upon this description to incorporate specific elements that should be addressed in the assessment, including content and chronicity of the SI, limited developmental progress, functional impairments, and substance abuse. Lieberman et al. (2014) recommends a multi-stage model of risk assessment that aids in early detection through the utili- zation of screenings and clinical interviews (Reynolds, 1991). The screenings should be brief, well-validated, and reliable; the follow-up clinical interview(s) with the individual and his/her support system, on the other hand, should be thorough in assessing ideation, plan, intent, risk factors, warning signs, and protective factors. Poland (1995) emphasized the importance of directly querying the student whether s/ he is actively thinking about death. He provided specific guidelines for SMHPs when assessing a student’s risk in Table 5.2.1 below.

Best practices for risk assessment include a step by step procedure that guide SMHPs to review and assess for all of the critical items dis- cussed previously. The Montana Crisis Action School Toolkit on Suicide (CAST-S), a suicide prevention program that was developed in a collaboration between the Big Sky Council and National Alliance for Mental Illness (NAMI) Montana to support Montana school communities in response to state legislation for school suicide prevention program- ming (Poland & Poland, 2017). The Montana CAST-S program’s steps include the identification of risk factors through the use of suicidal ideation severity scales, such as the Columbia Suicide Severity Rating Scale (C-SSRS, Posner et al., 2011), along with a detailed collection of family history, psychiatric concerns, precipitating stressors, presenting symptoms, and access to lethal means. Protective factors, both internal (e.g., fear of death, ability to cope with stress) and external (e.g., beloved pets, engaged in work or school) should be identified, followed by specific questioning about thoughts, plans, and suicidal intent. The CAST-S recommends utilizing the C-SSR’s Suicidal Ideation Intensity, as it includes direct and specific language that is necessary to determine the level of risk involved (see Montana CAST-S, Tool 14B: SAFE-T Protocol for the step-by-step recommendations [Poland & Poland, 2017, p. 79–83]).

It is important to highlight a specific factor of risk assessment that may be not specifically considered: language. The use of specific lan- guage is highly important in the course of proper suicidal assessment for an at-risk student. The use of phrases such as “kill yourself,” “suicide,” and “take your own life” is critical in the assessment process, as it aids in the differentiation of the type of self-harm the youth may be engaging in or intend to engage in. For example, a teen who engages in nonsuicidal self-injurious behaviors (e.g., cutting) as means to cope with over- whelming emotions or the absence of emotions may respond “yes” to a question that is less direct such as, “have you had thoughts of hurting yourself?” Additionally, most adolescents will respond “yes” to the question “have you had thoughts of dying?” given the developmental appropriateness of the consideration of mortality. Asking a student directly about having thoughts or desires to kill themselves not only creates a clearer path for querying, but also demonstrates an attitude of openness to discuss suicide with the youth (Erbacher et al., in press). The questions in Table 5.2.2 below can be found on the C-SSRS (Posner et al., 2011) and within the CAST-S′ toolkit; they showcase the direct nature of

Table 5.2.1 Suicide assessment recommendations for SMHPs.

Best practices: suicide assessment for SMHPs

▸ Connect with student through providing empathy, support, and trust. ▸ Reflect feelings, remain nonjudgmental, and do not minimize the problems. ▸ Respect student’s developmental, cultural, and sexuality issues while collecting necessary information considering appropriate community referrals. ▸ Utilize an assessment worksheet. ▸ Be direct in questioning the student, staff member, and/or parents when collecting information. ▸ Never promise confidentiality. ▸ Ensure that you are maintaining the chain of supervision at all times (Poland, 1995).

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the language recommended in best practices for risk assessment.

5.2.3. Safety plan No-harm/no-suicide contracts are used broadly in suicide interven-

tion, serving as a written documentation of the student promising not to act on thoughts of self-harm or suicide and to instead reach out to appropriate resources, e.g., loved ones, police. Despite their widespread use, no-harm/no-suicide contracts have become a controversial topic related to their effectiveness, especially due to the fact that there are no data to support their impact on the reduction of suicide (Rudd et al., 2005; Erbacher et al., in press). An alternate approach to no-harm/no- suicide contracts, and the current best practice standard of care, is to create a safety plan.

A collaborative creation of a safety plan between the student and SMHP is essential in the face of suspected suicidality and/or a reentry to school from a hospitalization. The design of this plan is flexible and can include a variety of components (Brent et al., 2011; King et al., 2013; Stanley & Brown, 2012). The goal of the safety plan is to provide a document that students can reference when experiencing suicidal ideation. Component of a safety plan include predetermined coping strategies, peer and adult supports, and professional resources; all of which can aid the student in working through the crisis. Specific rec- ommended elements include identified triggers and related thoughts, emotions, and behaviors, internal and external coping resources, a plan of how to access such resources in times of distress, an agreement to remove lethal means, and the contact number of appropriate crisis hotlines. As mentioned, this plan should be developed collaboratively with the student and shared with the parents or guardians. Lastly, the student must ensure that the plan is readily accessible when in need (Erbacher et al., in press).

Among the discussed components of a safety plan, it is important to expand upon a few items further. An agreement to remove lethal means is a critical aspect that can have a major impact on the trajectory of the student’s future decision making when in crisis. A common myth often pandered regarding restriction of means is that individuals whose access to lethal means has been removed will pursue an alternative method. In fact, research has documented quite the opposite, finding that if a spe- cific method is removed and unavailable, suicidal individuals are very unlikely to seek another method (Poland & Poland, 2017). The Means Matter website at Harvard University (Harvard Injury Control Research Center, 2019) provides comprehensive research that removing the lethal means, such as a gun, or raising the barrier on bridges, have decreased suicides.

An additional important aspect that requires further review is the

provision of both local and national suicide/crisis hotlines. This is an essential part of not only a safety plan, but general suicide prevention and intervention planning. As mentioned, this information should be made available during safety planning either during the risk assessment phase or after reentry from a hospitalization. Additionally, it should be made available to students and staff throughout the school environment. Students should be provided with the number for the National Suicide Prevention Lifeline 1-800-273-TALK (8255) and 911 (Suicide Preven- tion Lifeline, 2019).

Relatedly, students should be alerted to the alternate technical re- sources at their disposal, such as the Crisis Text Line (2013), in which at- risk students can text “HOME” to 741741 to receive 24/7 crisis support via text. Other options include Apple’s “Siri,” the application that en- ables users to complete tasks by speaking to their phone, which has recently undergone major changes in its response to suicidal behavior. Prior to June 2013, if an iPhone user told Siri that s/he wanted to jump off a bridge, Siri would provide a list of bridge locations. However, Apple has since reprogrammed Siri to return to such requests and others related to suicidality with the phone number for the National Suicide Prevention Lifeline. Further, Siri is prompted to then ask if the user would like her to call the number or provide a more detailed list of local suicide prevention centers on a map (Erbacher et al., in press; Stern, 2013). These avenues for help are invaluable resources for students in crisis and should be widely publicized in the school setting.

5.2.4. Referrals The notification of at-risk students to individuals who are in a posi-

tion to intervene has been reiterated throughout this paper, particularly in relation to the vital importance of gatekeepers in suicide prevention programs. As mentioned, appropriately trained individuals (e.g., peers, professionals) should be able to recognize warning signs of suicide and/ or be able to respond adequately to any observed suicidal behavior of students. Identification should prompt proper referrals to school personnel who are equipped with the skills to intervene (e.g., SMHPs). If SMHPs are not available, the Model Policy (AFPS et al., 2019) advises that the administrator or school nurse should provide care for the stu- dent until a SMHP or outside professional can be reached to complete a thorough risk assessment. As a reminder, the student should never be left alone once at-risk behavior is identified.

An additional and highly critical notification that must be completed is the notification of the parents or guardians. As discussed earlier, failure to notify parents has been cited as a major factor of negligence in numerous legal cases after a student’s suicide. As a result, it has been determined that a SMHP has an obligation to report any student who may be suspected for at-risk suicidal behavior based on foreseeability. It is important to note that often students will deny being suicidal; how- ever, even if a student denies SI, if he has been referred to a SMHP for suspected suicidality, it is the onus of the school to notify the parents or guardians. This should be the case for all students, elementary to high school. This is even the case for students over 18 years of age. Addi- tionally, any notifications should be completed in writing. If SMHPs do not follow through on this duty, it can be considered negligent in a court of law (Eisel v. Board of Education Montgomery County, 1991; Lieber- man et al., 2014). Notification to parents and guardians of a student who is suspected of being suicidal (unless abuse is suspected, in such cases protective services should be notified) is crucial, not only because of the possible legal implications, but also to ensure that they are alerted to the need to provide best care for the student’s safety.

Of note, should the tragic incident of a SA on campus be made, the Model Policy (AFPS et al., 2019) recommends that all students should be removed from surrounding areas as soon as possible and that the pri- mary concern should be for the suicidal student. Medical treatment should be provided, per district emergency medical policies and SMHPs or suicide prevention coordinators and parents and guardians should be immediately notified. Steps should then be taken to ensure the safety and well-being of students who have been exposed and/or impacted by

Table 5.2.2 Best practices: direct language for suicide assessment.

Severity of ideation

▸ Have you wished you were dead or wished you could go to sleep and not wake? ▸ Have you actually had any thoughts of killing yourself? ▸ Have you been thinking about how you might do this? ▸ Have you had these thoughts and had some intention of acting on them? ▸ Have you started to work out or worked out the details of how to kill yourself? ▸ Do you intend to carry out this plan? ▸ Have you ever done anything, started to do anything, or prepared to do anything to end your life? (C-SSRS, Posner et al., 2011)

Thoughts, plans, and suicidal intent

▸ Frequency: How many times have you had these thoughts? ▸ Duration: When you have the thoughts, how long do they last? ▸ Controllability: Could/can you stop thinking about killing yourself or wanting to die if you want to? ▸ Deterrents: Are there things—anyone or anything (e.g., family, religion, pain of death)—that stopped you from wanting to die or acting on thoughts of suicide? ▸ Reasons for Ideation: What sort of reasons did you have for thinking about wanting to die or killing yourself? (C-SSRS, Posner et al., 2011)

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the SA, albeit such methods may vary from district to district (Vaillan- court & Gibson, 2014).

Once risk is assessed and parents have been notified, an action plan should be collaboratively developed with school personnel, family members, and outside professionals. Referrals for treatment should occur. Lieberman et al. (2014) recommended that SMPHs maintain a current list of community mental health resources to use as referrals for at-risk students. Of importance, both the SAMHSA (2012) toolkit and the Montana CAST-S (Poland and Poland, 2017) advise schools to complete pre-screenings of said resources. Specific questions should be asked to private providers prior to completing referrals related to professional qualifications (e.g., Do you have experience working with LGBTQ stu- dents and other groups that are disproportionately at risk for suicide?, What process do you follow in the event of a suicide crisis?) and business logistics (e.g., do you offer a sliding scale fee?, What is your typical wait time to see a new client? [see p. 119 Tool 28: Screening Mental Health Providers, Montana CAST-S, 2017]). Once an action plan is in place for the student and his/her parent/guardian has secured treatment, the authors recommend that the designated reporters or SMPHs make con- tact with the referral provider in to provide a comprehensive review of what took place. Moreover, various factors such as developmental, cultural, socioeconomic (potential need for provider who offers sliding scale rates), and sexuality issues should be considered when making such referrals (Lieberman et al., 2006; Lieberman et al., 2014).

Lastly, it is important to comment on a critical component of re- ferrals: the need for thorough and clear written documentation on behalf of the SMHPs and related school personnel. It should be completed on the day of the assessment/incident and content collected through in- terviews and assessments should be written down verbatim. Documen- tation such as this is essential in the referral of a student to both crisis response teams and related mental health professionals. School districts should provide specific forms for documenting in order to guarantee that proper records are kept of their responses, actions taken, recommen- dations, and referrals made to a suicidal student and/or the individual’s parents (Lieberman et al., 2008).

5.2.5. Re-entry The implementation of specific policies for handling students who

return to school after engaging in suicidal behaviors is consistently recommended. While each school and district’s procedures may vary, The Model Policy (AFPS et al., 2019) has identified key aspects of a re- entry plan, including:

▪ A designated SMHP will coordinate with the student, family, and any outside mental health providers (if permission was granted).

▪ The parent or guardian will provide sufficient medical docu- mentation that the student is no longer a danger to themselves or others.

▪ The designated SMHP will determine what supports are needed to help the student readjust to the school community and meet with him or her periodically to address any concerns (Vaillan- court & Gibson, 2014).

Lieberman et al. (2014) expanded upon these recommendations, reporting that it is essential to facilitate the student’s re-entry in a “careful [and] precise manner” (p. 282, Lieberman et al., 2014). They recommended a multidisciplinary meeting between any and all in- dividuals (e.g., parents, teachers, SMHPs, administrators, outside mental health professionals, medical staff) that can aid in mediating a successful reintegration into the school environment. As mentioned previously, a safety plan should be collaboratively created if one was not already done so in outside care. The Montana CAST-S (2017) provides a useful checklist for school reentry for administrators, SMHPs, and staff mem- bers. It includes a step by step guide for how each professional should approach the reintegration process for a suicidal student (see p. 101,

Tool 20: Checklist for School Reentry of Suicidal Student). The authors caution individuals who are wary to return to school, as it has been found that a depressed child is safer in school than not. Of note, while these are guidelines for best practice for re-entry procedures, it is always imperative that SMPHs review and adhere to their individual districts policies.

5.3. Postvention

Specific and consistent guidelines have been provided by experts for the coordinated response schools should take following a death by sui- cide in the school community, i.e., postvention (AFPS, 2019). Postvention is a term unique to the literature related to suicidality and encompasses specific activities or events that are planned for schools to implement following a suicide in order to evaluate the overall impact, identify at- risk individuals, prevent a contagion effect from occurring, and sup- port survivors who are emotionally affected by the death to cope effectively (Lieberman et al., 2014). Just as important as prevention, postvention is a critical aspect of adequately addressing suicidality in the school context. The rationale behind this is that a timely response to suicide in the school community aids in a reduction of potential subse- quent morbidity and mortality among exposed students, inclusive of the onset of symptomology related to depression, posttraumatic stress dis- order, and bereavement, along with suicidal behaviors (Gould et al., 2003; Singer et al., 2018; Talbott & Bartlett, 2012). Postvention pro- grams are designed to target the goals of assisting survivors in the grief process, identifying and referring at risk individuals, providing accurate information about the suicide while attempting to minimize suicide contagion, and coordinating a plan for continued prevention efforts (Gould et al., 2003; Hazell, 1993; Lieberman et al., 2014; Underwood & Dunne-Maxim, 1997).

Vaillancourt and Gibson (2014) provided an integrated guideline for postvention strategies based upon The Model Policy (AFPS et al., 2019) and resources from The National Association of School Psychologists (NASP). Postvention programs that follow these guidelines will ensure comprehensive follow up and support in response to a tragic loss in the school community and buffer against suicide contagion among students. The contagion effect of suicide is a major concern in the realm of youth suicidality. Rooted in social learning theory, contagion effects in the context of suicidal behaviors refer to the idea that upon being exposed to suicide (via peers, family members, celebrities, the media), young peo- ple may learn that it is the only permanent solution to their difficulties, creating higher risk for SI/SA (Lieberman et al., 2014).

Youth have been found to be especially vulnerable to the contagion effect, creating suicide point clusters (suicides are contiguous in time and space) in schools and communities across the nation, such as Palo Alto, CA (2002, 2009, 2014), Fairfax County, Virginia (2014), Colorado Springs, Colorado (2017), and Salt Lake City, Utah (2018 [Poland et al., 2019]). A review of point clusters revealed specific risk factors including male gender, mental health issues, history of suicidal ideation or suicide attempt, substance abuse issues, relationship problems, a recent crisis, cutting behavior, parents not recognizing the severity of the mental health needs of their child, sleep deprivation, academic pressure, sexual orientation, and intimate partner violence (Annor et al., 2017; Garcia- Williams et al., 2016; Poland et al., 2019; Spies et al., 2014). Such factors are vital pieces of information to school personnel in the wake of a student suicide, providing increased awareness to at risk youth.

While individual circumstances surrounding a suicide will guide the school and community response, it is important that schools obtain reliable information in order to help their students cope with and respond to the loss. An action plan should be developed in which several steps are taken: (1) details of the student’s death are verified by the local police department or coroner’s office, (2) the impact of the suicide on the students and community is assessed by the school/district crisis team and appropriate resources for individual and universal student needs are identified, (3) factual information is shared to school personnel,

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students, and their families, inclusive of the resources and supports available in the school and community, (4) high risk students, e.g., close friends of the student who died, are identified in order to decrease sui- cide contagion, (5) further risk assessment of students is completed and provision of support services is offered, and (6) creation a memorial plan with the student’s friends and family that is both a safe and meaningful approach to acknowledging the loss without any glamorization or perpetuation of the stigma of suicide (Vaillancourt & Gibson, 2014).

Poland et al. (2019) further support these recommendations for ac- tion planning in postvention and provide a more current and detailed review of each step that should be taken. Furthermore, they introduce a valuable resource for postvention planning: “After a Suicide: Toolkit for Schools Second Edition” (AFPS & SPRC, 2018). The toolkit is recom- mended as an appropriate postvention guideline for addressing a suicide among the community. Best practice guidelines in the aftermath of a suicide are offered, including crisis response, helping students and school personnel cope, collaborative efforts with the community (e.g., government agencies, mental health providers) and media (a necessary relationship in order to appropriately report on the suicide and minimize contagion [Lieberman et al., 2014]), memorialization, social media, and buffering suicide contagion. An overarching recommendation from the AFPS Toolkit is that all deaths should be treated in the same way. Schools are encouraged to develop a memorialization policy and to do the same thing after a death regardless of cause of death, popularity, or socioeconomic level of the deceased. In order to provide the best care to the school/community, this toolkit outlines very specific courses of both appropriate and inappropriate actions to take after a completed suicide in the school community.

Even more sparse than the existing research on school-based pre- vention programs, is that on school-based postvention programs. Rob- inson et al. (2013) systematic literature review of school-based suicide prevention programs discussed the significant gap in the research regarding reviewed postvention programs, noting that majority of the literature includes case studies and anecdotal information. Gould et al. (2003) similarly lamented to paucity of research in this area, finding only two studies that examined the efficacy of school-based postvention programs in the reduction of student suicidal behavior. The first, Hazell and Lewin (1993) revealed no differences in their comparison outcomes of the intervention group vs. the control group. Poijula et al. (2001) small scale study, on the other hand, did demonstrate interesting results, finding that in a 4-year-follow-up, no new suicides took place in schools that incorporated appropriate interventions, whereas in schools that did not have interventions, suicides increased significantly. The present authors echo historical concerns regarding the lack of research in this area, given the serious risks of exacerbation of distress for survivors and the potential of contagion.

6. Conclusion

The aim of this paper was to provide a critical review of youth suicide in the school context. The information reviewed was gathered from a variety of sources, including empirical findings, systematic literature reviews, expert recommendations, and government generated content. This review covered the important areas related to suicide in the school setting, including current trends, relevant risk and protective factors, legal issues, prevention, intervention and postvention, along with spe- cific guidelines for best practices. The in-depth exploration is a helpful map for generating a comprehensive conceptualization of youth suici- dality in the school environment.

Given the ongoing public health concern that youth suicide presents, along with the demonstrated findings of seasonal variations and asso- ciated risk factors related to the school milieu, continued examination of suicidality in the school context is imperative. While this is generally acknowledged across both school and mental health professionals, there is still a lack of consistent implementation nationwide. Dr. Scott Poland noted specific roadblocks that he has encountered in his professional

collaborations, including a lack of awareness of the problem, lack of training and acceptance of shared responsibility, the presence of competing demands at the school, fear to openly talk about suicide, failure to recognize legislative requirements for training and utilization of prevention programming, and limited or no collaboration with community services and prevention initiatives (Erbacher et al., in press). AFPS (2019) is dedicated to broadening the scope of prevention prac- tices in the school setting and will need support from professionals, families, and organizations to further their mission.

As discussed, school personnel play a critical role in targeting youth suicide in a myriad of ways. It is imperative that they receive appro- priate training in the identification of at-risk youth. As a reminder, lack of training has been connected to significant legal implications, some of which have generated clarity on the school’s role in this matter. Lia- bility, however, remains to be considered a distinct precedence across states. Prevention programs should be in place in every school nation- wide, in which a hybrid approach is utilized, incorporating helpful screening methods, gatekeeping, and psychoeducation for students, staff, and parents. When making decisions on program choice, schools should utilize evidence-based resource databases, such as those com- plied by both SPRC and SAMSHA, in which many of the resources and programs discussed can be reviewed. Trained SMHPs who can complete appropriate risk assessments and necessary interventions must be incorporated. Notification of the parents or guardians is a critical factor of school-based suicide intervention and failure to so do can result in serious legal consequences. Identification of appropriate referral re- sources for mental health treatment is recommended and ongoing collaboration with such providers can be helpful. Lastly, postvention efforts must be made in order to properly meet the needs of grieving survivors and to minimize the potential of a suicide contagion.

A variety of programs, organizations, materials, and resources have been discussed throughout this paper and are key contributors to the ongoing research in this field. A list of pertinent resources to address suicide in the school context can be found below:

▪ Centers for Disease and Control: “Youth Risk Behavior Sur- veillance Survey” (2017) (Centers for Disease Control and Prevention (CDC), 2017a).

▪ American Foundation for Suicide Prevention (AFPS): “Model School District Policy on Suicide Prevention” (2019) (American Foundation of Prevention for Suicide (AFPS) et al., 2019)

▪ The National Association of School Psychologists (NASP): “Guidelines for Administrators and Crisis Teams” (National Association of School Psychologists, 2015)

▪ Suicide Prevention Resource Center (SPRC): “Preventing Sui- cide: The Role of High School Mental Health Providers” & “Preventing Suicide: The Role of High School Teachers” (Sui- cide Prevention Resource Center, 2019)

▪ AFPS & SPRC: “After a Suicide, a Toolkit for Schools Second Edition” (2018) (American Foundation of Prevention for Sui- cide (AFPS) and Suicide Prevention Resource Center (SPRC), 2018)

▪ Substance Abuse and Mental Health Services Administration (SAMHSA): “Preventing Suicide: A Toolkit for High School” (Substance Abuse and Mental Health Administration (SAMHSA), 2019)

▪ Poland & Poland in collaboration with Montana OPI, SAM, DPHHS, Big Sky AACAP, and NAMI Montana: “Montana Crisis Action School Toolkit on Suicide”(CAST-S) (Poland and Poland, 2017)

▪ SPRC: Resources and Programs Database (Suicide Prevention Resource Center, 2019c)

▪ SAMSHA: Evidence Based Practices Resource Center (Sub- stance Abuse and Mental Health Administration (SAMHSA), 2019)

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▪ President and Fellows of Harvard College: Means Matter (Harvard Injury Control Research Center, 2019)

7. Future directions and additional recommendations

An important aspect of this review is the consistent finding of limited evidence-based programming for prevention, intervention, and post- vention. While some empirical findings are present across the literature, researchers criticize the lack of RCTs and repeated trials examining school-based program effectiveness on youth suicide outcomes. As such, the present authors join other critics in the field and encourage re- searchers to focus their efforts on empirically examining suicidality in the school context. Despite the limited availability of evidence-based programs, a wealth of recommendations for best practices is present across the literature, all of which are grounded in scientific findings and expert knowledge.

A variety of programs and toolkits have been reviewed; as mentioned, while these are comprehensive resources, they are limited to middle and high school populations. However, recall the CDC’s (2017b) finding that suicide is the second leading cause of death for ages 10–34, indicating that students in elementary grades are engaging in suicidal behaviors. Moreover, recent studies that have investigated common risk factors and trends related to risk factors and trends in suicidal behavior in elementary-aged students have suggested the need for suicide pre- vention efforts that are adapted to be developmentally appropriate for this population (Bridge et al., 2015; Sheftall et al., 2016; Singer et al., 2018). As such, the authors call for further research related to this population and the creation or adaption of additional resources for elementary grade levels.

The presence of school-based programming continues to grow; however, schools are faced with the challenge of finding evidence-based and best practice programs given the limited unified support in legis- lation. Many states are still operating without specific legislative guid- ance or requirements for prevention efforts. While there is guidance available on this matter, the variation due to individual school districts and policies can create challenges in broad implementation. Continued lobbying for government and legal changes for better practices are necessary and can be further pursued through organizations like ASFP.

The authors recommend that all states enact legislation that requires suicide prevention in schools. Included in this prevention should be a one-hour (at minimum) annual training for all school personnel who interact with students, including support staff such bus drivers, cafeteria staff, administrative assistants, and paraprofessionals. In states in which legislative requirements have been set forth, it is imperative that the Department of Education has procedures in place to assess whether or not the legislation is being implemented. Given the wealth of informa- tion reviewed related to suicide in the school context, it is vital that professionals across fields (school, legal, clinical, community) continue to push for increased attention, research, and programming to aid in the prevention and reduction of youth suicide.

Declaration of competing interest

None.

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S. Poland and S. Ferguson

  • Youth suicide in the school context
    • 1 Introduction
    • 2 Youth suicide & seasonal variations
    • 3 Risk factors in the school context
      • 3.1 Social connectedness
      • 3.2 Bullying
      • 3.3 LGBTQ population
      • 3.4 Ethnicity and culture
    • 4 Legal implications of suicide in the school context
      • 4.1 School liability: relevant legal cases
      • 4.2 Legislation
    • 5 Addressing youth suicide in the school context
      • 5.1 Prevention
        • 5.1.1 School suicide prevention programs
        • 5.1.2 Enhancement of protective factors
        • 5.1.3 Screening tools
        • 5.1.4 Gatekeeper trainings
        • 5.1.5 Curriculum based programs
        • 5.1.6 Peer leadership
      • 5.2 Intervention
        • 5.2.1 Identification of at-risk youth
        • 5.2.2 Risk assessment
        • 5.2.3 Safety plan
        • 5.2.4 Referrals
        • 5.2.5 Re-entry
      • 5.3 Postvention
    • 6 Conclusion
    • 7 Future directions and additional recommendations
    • Declaration of competing interest
    • References